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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): E}0�e Spo+ <br /> Address for Vehicle: PO Qax 534 Co, °1S3$a <br /> Street Address City <br /> 1) License Plate#: H HG 222-• 4) Year: 200 <br /> 2) Vehicle Vin #: 50O592gp'4 5) Make/Model: fABWE � s-ttcrr' <br /> 3) State Decal #: C-A 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: L-\-A5 i rnc.y-,8 -.\vo�ie.Z <br /> Address of Owner` P-C) t�ox W ! -\e Ccs qS3� <br /> Street Address City <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office may result i�t revocation and penalties. <br /> ��- �� • 201$ <br /> Signature of Vehicle O ator Date <br /> COMMISSARY INFORMATION <br /> Business Name: Cold Storage Commissary Inc. DBA: La Comisaria Modesto <br /> Owner Name: Arturo Vaca: Manager <br /> Site Address: 500 7th St. Ste. D Modesto, CA 95354 <br /> Street Address City <br /> Phone: ( 209 ) 338-3663 <br /> I,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> FV Liquid&solid waste disposal Utensil washing sink Store frozen food <br /> q p (2 or 3 compartments) Vehicle wash facilities <br /> Preparation of food Hot& cold water for cleaning Toilet&hand washing ® Store refrigerated food <br /> Store dry f od/supplies Provid potable water Overnight parking Adequate electrical outlets <br /> 0- � , Ig <br /> 1q,adfure of Commissary Owner/O erator Date <br /> EALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County RENS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />